Q: Is a log necessary for tracking grievances? It is not in the compliance indicators for the grievance process standard, but it is something we were asked to show to the surveyors during our NCCHC survey.

A: You are correct, Standard A-10 Grievance Process for Health Care Complaints does not specifically require a grievance log. However, a detailed record of grievances can provide valuable feedback regarding opportunities for improving health services and can be an important source of information for your continuous quality improvement program. Having all grievances (regardless of founded or unfounded results) tracked on a log makes it easy to review topics for a CQI study at your facility. The log can be designed in whatever format is most functional for your CQI program; however, many find it valuable to track the nature of the grievances by topic, monthly totals for each topic, duration (in days) of response time, and whether the grievance was founded or unfounded after investigation.

Wendy Habert, MBA, CCHP, is NCCHC’s new director of accreditation. Send your standards-related questions to accreditation@ncchc.org.